psychometric properties of instruments assessing

Journal of Behavioural Sciences, Vol. 31, No. 1, 2021

Psychometric Properties of Instruments Assessing Psychosocial

Predictors of Coronary Heart Disease

*Rafia Rafique, PhD

Institute of Applied Psychology, University of the Punjab, Lahore,

Pakistan

Afsheen Masood, PhD


Pakistan

Fatima Kamran, PhD


Pakistan

Naumana Amjad, PhD


Pakistan

This study was designed to translate the instrument used to assess

the risk and protective predictors of Coronary Heart Disease (CHD) into

the Urdu language and to determine their psychometric properties. The

majority of the Pakistani population lacks fluency in English and that

reprimands a toll that must be used in the indigenous local language. The

investigation included 42 participants while the entire process of

translation carried 10 sequential stages. The study sample included 20

bilingual cases, ages ranging from 35 to 55 years, who were matched on

gender and obtained from the community controls group. Psychosocial

measures proposed on the basis of literature review to assess risk and

protective predictors of CHD included: The Perceived Stress Scale

* Correspondence concerning this article should be addressed to Prof. Dr. Rafia Rafique,

PhD, Professor and Director Institute of Applied Psychology, University of the Punjab,

Pakistan. Email: [email protected]. Afsheen Masood, PhD, Assistant Professor,

Institute of Applied Psychology. Fatima Kamran, PhD, Associate Professor, Institute of

Applied Psychology and Dr. Naumana Amjad, PhD.

mailto:[email protected]

6 RAFIQUE, MASOOD, KAMRAN AND AMJAD

(Cohen, Kamarck, & Mermelstein, 1983); Center for Epidemiological

Studies Short Depression Scale (Radloff, 1977); State-Trait Anxiety

Inventory (Spielberger, 1983); State-Trait Anger Expression Inventory

(Spielberger, 1988); Personality Deviance Scale-Revised (Bedford &

Foulds, 1978); Revised Life Orientation Test (Scheier, Carver, &

Bridges,1994); Perceived Locus of Control Scale and Multidimensional

Scale of Perceived Social Support (Zimet, Dahlem, Zimet, & Farley,

1988). To ensure a rigorous process of translation and to achieve

equivalence between the original version and translated versions of

scales, Vallerand’s (1989) steps for instrument translation with slight

modification were employed. The results showed that there were no

significant differences in the mean scores of English and Urdu versions

on any of the scales, suggesting similar dissemination of the content of

the scales in Urdu and English. Pearson correlation analysis between pre

(English) and post-administration (Urdu) revealed a significant positive

correlation demonstrating reasonably high validity for all the scales. The

alpha coefficients revealed moderate to high level of internal consistency

of all scales for both administrations respectively. The translated

instruments can be used in the routine medical assessment to assess the

risk and protective predictors of CHD.

Keywords: Coronary heart disease, perceived stress, perceived locus of

control

Recent advancements in research on CHD have evolved by

integrating multiple psychosocial and behavioural factors, besides

biological factors that have been responsible for the progression and

onset of CHD. There has been a large volume of clinically impressive

research evidence that confirms the role of psychosocial risk factors that

are involved in the etiology of CHD (Strike & Steptoe, 2004; Rosengren

et al., 2004). Researchers have demonstrated that the risk of psychosocial

factors in the onset of CHD is greater than clinical or demographic

factors in some cases of CHD (Kubzansky & Kawachi, 2000).

Research evidence shows that many psychosocial factors have

been extensively studied in relation to CHD. Negative emotional states

(State-Trait Anxiety) and traits have been extensively studied in relation

PSYCHOMETRIC PROPERTIES OF INSTRUMENTS FOR CHD 7

to CHD (Kubzansky & Kawachi, 2000). Researchers investigating anger

and hostility have predominantly preferred Spielberger State-Trait

Anxiety (STAI) and Spielberger’s Anger Scales (STAXI) as measure

instruments (Raikkonen, Matthews, Sutton-Tyrrell, & Kuller, 2004).

Hostility and dominance both have also been measured by subscales of

Bedford-Foulds Personality Deviance Scales (Whiteman, Deary,

& Fowkes, 2000). The Revised Life Orientation Test (LOT-R) has been

extensively used to measure optimism in cardiovascular research

(Robbins et al., 1991). Diverse measures to assess depression and its

association with cardiovascular diseases have been employed namely the

Center for Epidemiological Studies Depression Scale (CES-D)

(Blumenthal et al., 2003), Beck Depression Inventory (BDI) (Lauzon et

al., 2003), Hospital Anxiety and Depression Scale (HADS) (Mayou et al.,

2000) and Depression Anxiety and Stress Scale (DASS) (Baker, Andrew,

Schrader, & Knight, 2001).

Likewise, many measures have been employed to measure

perceived stress in cardiovascular research like The Reeder Stress

Inventory (Macleod et al., 2002) and 50 item Life Inventory (Sweeting &

West, 1994), Hassles Scale (Reich, Parrella, & Filstead, 1988), and Stress

Reaction Scale (Robbins et al., 1991).

Perceived Control/locus of control in relation to health and

particularly CHD have been measured by questions adapted from the

Whitehall II Study (Marmot et al., 1991). Since then, many studies have

utilized these questions to address issues relating to CHD (Yusuf et al.,

2004). Perceived Social Support has been measured by a subscale of the

Interpersonal Support Evaluation List (Chen, Gilligan, Coups, &

Contrada, 2005) and the Multidimensional Scale of Perceived Social

Support (Zimet, Dahlem, Zimet, & Farley, 1988).

Ischemic Heart Disease (CHD) occurs to a greater extent in

developed than developing countries like Pakistan. Our understanding of

risk factors leading to this disease thus is largely derived from studies

carried out on samples obtained from developed countries. As the

instruments used to assess the risk and protective psychosocial factors

associated with CHD are not in the indigenous language, most of the


research carried out in Pakistan has focused on biological and behavioral

predictors of CHD (Rosengren & Wilhelmsen, 1997).

Since the prevalence of CHD in Pakistan is growing, it seems

pertinent to infer psychosocial factors of CHD besides the traditional

factors within the Pakistani population. This goal can be achieved if we

can translate these psychosocial measures into Urdu language and

establish psychometric properties.

So this study was designed with a primary purpose to ensure the

rigorous process of forwarding and backward translation and to achieve


scales. The purpose was to decrease the risks of errors and improve the

precision of translations through the process of forward and backward

translation. A secondary objective was to determine the psychometric

properties of the translated instruments through the process of validation.

Method

This study was designed to translate all the original scales into Urdu

language and determine their psychometric properties, through the

process of content validation. The forward-translations and back-

translations were the methods employed.

Figure 2.1. Flow chart depicting the total number of individuals

involved at different stages of the process of tool translation.

Determination of Psychometric Properties of the Scales

Sample


The study sample included 20 bilingual cases, both men and

women, age ranging between 35 to 55 years, taken from two leading

Cardiac hospitals of Lahore. The research participants were

systematically matched on gender and were recruited through a non-

probability purposive sampling strategy.

Inclusion Criteria

Cases were recruited only if they had Angina with chest pain, or

chest pain established as Angina or patients with the first onset of acute

myocardial infarction (AMI), whose diagnoses had been confirmed by

the cardiologists on the basis of clinical symptoms or changes in the

electrocardiogram, or raised concentration of troponin levels. Angina and

AMI patients experiencing the clinical conditions for the first time were

included in the study.

Exclusion Criteria

Patients experiencing the following sign and symptoms were not

included in the study sample: patients who had undergone cardiogenic

shock or chest pain due to non-cardiac reasons; patients suffering from a

significant chronic medical illness, pregnant females, as well as patients

with a prior psychiatric history; Patients, having a previous history of

treatment for heart disease like Coronary artery bypass graft (CABG)

surgery; participants failing to provide informed consent and patients

who were unable to read or write exclusively Urdu or English language.

Community-based controls recruited in the study were attendants,

visitors or relatives of the cardiac patient, unrelated (not first-degree

blood relatives) having no previous diagnosis of heart disease or history

of exertional chest pain. Exclusion criteria followed for community

controls were the same as that set up for the cases.

Instruments

The instruments listed below were translated into Urdu and semi-

standardized.

The Perceived Stress Scale (PSS). Cohen, Kamarck, and

Mermelstein (1983) developed The Perceived Stress Scale (PSS)


comprising of 10 item scale. Each item is measured on a 5-point Likert-

type scale (0 = never, 4 = very often). The PSS has four positively

worded items (4, 5, 7 & 8) that are reversed scored. A total score on the

scale is obtained by adding all scores across the 10 items. The internal

reliability of the scale has been found to be 0.78 (Cohen & Williamson,

1988).

Center for Epidemiological Studies Short Depression Scale

(CES-D 10). Radloff, (1977) developed this 10-item scale to measure

self-reported depressive symptoms Items on the CES-D 10 use a 4-point

Likert-type scale (0 = rarely or none of the time and 3 = all of the time).

Two items (5 & 8) are reverse scored, and the total score is obtained by

summation of scores of these 10 items. The scale has high reliability (α =

.85) for general population (Fisher & Corcoran, 1994). The scale has

good concurrent validity, known- group validity, and discriminant

validity (Fisher & Corcoran, 1994).

State-Trait Anxiety Inventory (STAI). In 1983, Spielberger

developed 20-items State-Trait Anxiety Inventory (STAI) to measure the

general tendency to respond to perceived threats in the environment with

anxiety. Each item is measured on a 4-point Likert-type scale (1= not at

all and 4 = very much so). There are seven items (21, 26, 27, 30, 33, 36

& 39) that are reversed scored. The higher scores represent greater trait

anxiety. The reliability coefficients ranged from α = .65 to .86

(Spielberger, Gorsuch, & Lushene, 1970).

State-Trait Anger Expression Inventory (STAXI). Spielberger

developed this inventory in (1999). It consists of 10-items that measure

state and trait anger on a 4-point Likert type scale (1 = almost never and

4 = almost always). Trait anger temperament (T- Ang/T) score is

obtained by a composite score of four items (16, 17, 18 & 21), and the

total score on items (19, 20, 22, 23, 24 & 25) gives a score of trait anger

reaction (T- Ang/R). The total score on trait anger is obtained by adding

the score obtained on all 10 items. Scores on this scale can range from

10-40, with a higher score representing greater trait anger. The internal

reliability of the scale is α = .82 (Spielberger, 1999).


Personality Deviance Scale-Revised (PDS-R). Bedford and

Foulds, developed Personality Deviance Scale-Revised (PDS-R) in 1978.

The original scale consisted of 36 items that measured Hostile Thoughts

(HT), Denigration of Others (DO), Lack of Self-Confidence (LSC),

Dependency (DEP), Hostile Acts (HA), and Dominance-Submissiveness

(DOM-SBM). Two subscales: Hostility and Dominance/Submissiveness

were employed in this study.

Eight items of the hostility subscale were incorporated in the

current study (Bedford & Foulds, 1978). This hostility scale has four

possible responses on each item (4 = very often and 1 = never). A

possible score on PDS-R hostility scale ranges from 8 to 32, with higher

scores representing greater hostility. High reliability of .72 has been

reported for this scale (Bedford & Deary, 2003).

To measure DOM-SBM, a subscale of PDS comprising of 6 items

(Bedford & Foulds, 1978) with four possible responses on each item (4 =

very often and 1 = never) was used. All six items were reversely scored

to measure dominance, the possible score on this subscale ranges from 6

to 24 with a higher score representing greater dominance. The reliability

of PDS-R was found to be .75 (Bedford & Deary, 2003).

Revised Life Orientation Test (LOT-R). Scheier, Carver, and

Bridges (1994) developed a 10-item scale with a 5-point Likert-type scale

(0 = strongly disagree and 4= strongly agree) to measure generalized

optimism (versus pessimism). Each item is measured on the scale has

four filter items (2, 5, 6 & 8), that measure generalized expectancies for

positive versus negative outcomes and four items (3, 6, 7 & 9) are

reversed scored. The total score on optimism versus pessimism was

obtained by adding scores on items (1, 3, 4, 7, 9, & 10). The score on this

scale can range from 0 to 32, higher scores representing greater

optimism, and the internal reliability of the scale is α = .82 (Scheier et al.,

1994).

Perceived Locus of Control Scale (PLCS). Rosengren et al.,

2004 developed these six items to assess locus of control in cardiac

patients. These six items have been used expansively in studies


conducted in Eastern Europe (Marmot et al., 1991; Rosengren et al.,

2004; Yusuf et al., 2004). Research participants were asked to which

extent they agreed or disagreed with the statements. Two items (1 & 3)

were coded as (0 = strongly disagree and 4 = strongly agree) and the rest

of the 4 items (2, 4, 5 & 6) were reverse scored as they were negatively

worded and revealed less perceived control.

Multidimensional Scale of Perceived Social Support (MSPSS).

Zimet et al., (1988) authored this 12-item scale with 7 points Likert-type

response (1 = very strongly disagree and 7 = very strongly agree). A

composite score is obtained by adding the scores on all 12 items and

dividing it by 12 wherein a higher average score means greater perceived

social support. Cronbach's alpha for the scale is .78 (Zimet, Powell,

Farley, Werkman, & Berkoff, 1990).

Procedure

Permission for translation and use of instruments for conducting

the present study was appropriately sought from authors of all the scales.

To ensure a rigorous process of translation as well as to achieve


scales, Vallerand’s (1989) steps for instrument translation with slight

modification were employed (see also Banville, Desrosiers, & Genet-

Volet, 2000; Wongsri, Cantwell, & Archer, 2003). In order to get an

overview of stages followed for the process of translation in this study

(see Figure 1) To determine the psychometric properties of the scales, a

permission letter explaining the nature of the study and requesting

cooperation for the collection of data was sought from hospital

authorities. Cases and controls have explained the nature of the study and

requested to sign the informed consent form. Study participants were then

administered the English version of the scales, with the commitment that

they would return to the hospital again after one month to complete the

Urdu version of the same scales. After one month, the same study

participants were requested to fill in the translated Urdu version of the

scales by avoiding recall of how they had responded to these scales

previously in English.

about:blank


Figure 1. Flow chart depicting stages followed for the process of

translation, adopted from Vallerand’s methodology (1989).


Description of translation stages.

Stage1. Translation (English version into Urdu). Translation of

all English versions of scales into Urdu was carried out by six bilingual

native expert speakers living in Pakistan. All translators had prior

experience in translation. The translators were instructed to translate all

of the items of the scales, keeping in mind conceptual rather than the

literal meaning of the items by considering the population with at least a

primary level of education. Translators were also asked to identify items

as well as response options which they found difficult to translate, by

providing feedback on a scale ranging from (0 = not at all difficult, to 4 =

extremely difficult). All the translators involved in forward translation at


this stage rated nine items to be extremely difficult (I feel blue and I

could not “get going”), three items to be very difficult (I feel like crying

and It's important for me to relax) whereas six items were found to be

slightly difficult (I try to avoid facing a crisis or difficulty and I feel

infuriated when doing a good job and get poor evaluation) by these

translators.

Stage 2. Rating of translated scale items by native experts. All

translations obtained after the forward translation procedure were rated

by three bilingual native speakers, (see Figure 1) on a Thurston scale (4 =

Excellent, 3 = Very good, 2 = Good, 1 = Fair, and 0 = Poor) to facilitate

the selection of response choices that had similar value as that of the

original English translation. The average rating given by all three

translators was (3= Very good).

Stage 3. Panel discussion. The next stage involved an item by

item review of all six translations in a panel discussion comprising of six

members (see Figure 1). The final target version of the translation was

produced after comprehensive discussion keeping in view the individual

differences in all the six translations, length of items, differences in the

use of words and expressions, redundancy of words in items,

comprehension ability by the layperson, and cultural as well as regional

connotations.

Stage 4. Second-panel discussion for reaching on mutual

consensus for items identified as being problematic. Problematic

items, for which a mutual consensus was not reached by the members of

the previous panel discussion, were taken up by another voluntary panel

that comprised of six members (see Figure 1), all of whom were patients

diagnosed with CHD. This second panel gave feedback regarding the

elicitation of expressions that conveyed the concept under study. Three

members of this panel had attained education up to the primary level and

the remaining three members of the panel were college graduates. Eight

items that were found to be problematic and for which a mutual

consensus could not be achieved were excluded.


After the second panel discussion, a final draft of comprehensive

target translation: the forward translation based on mutual agreement on

item wise review was produced.

Stage 5. Proofreading by an expert in the Urdu language. This

final draft was given to an expert in the Urdu language for proofreading

as well as the elimination of any language expression or grammatical

errors, and thus a final draft was prepared by the researcher in

consultation with the expert in the Urdu language.

Stage 6. Backward translation. The proof-read draft, thus

finalized, was then backward translated by three (blind review-

translators) who were known language experts with established

competence in English as well as the Urdu Language (see Figure 1) and

were not familiar with the original scales. All three translators were given

the same instructions as previously given to the six translators who were

involved in the forward translation procedure.

Stage 7. Panel discussion (Bilingual experts). A panel of five

bilingual experts was formulated to review similarities and differences

between the original English version of the scales and the back-translated

version. This panel provided a qualitative review for every translated

item to ensure clarity in language, use of common language as well as

conceptual adequacy of items. Some of the items that were found to

reveal a discrepancy in meaning between the original English version and

the back-translated version were highlighted and alternatives were

proposed for these items. Ten items (10, 16, 20, 23, 25, 27, 31, 35, 40,

and 64) out of 97 were found not to reflect the original intent (in

grammar and context) and hence, were re-reviewed by the panel

accurately. After a lengthy panel discussion, a mutual agreement was

reached on the most appropriate translation and a final draft of the

consensus translation was produced following 100% agreement by all the

members of the designated panel on all items.

Stage 8. Lay Men community representative panel discussion.

The final draft of translated and corrected items was reviewed by five lay


people from the general community, aged between 35 to 55 years. This

panel comprised of three men and two women; among them, 1 male

member of the panel discussion had completed 12 years of education

while the remaining others have ten or fewer years of education. This

variation in education was deliberated to maintain community

representation features. The panel was instructed to identify difficult

items and propose alternatives by writing them on the draft directly. All

the members of the lay panel discussion were asked to write down any

suggestions regarding these items if they had any, however, none of the

items were identified as difficult or troublesome and the final draft was

thus approved.

Stage 9. Qualitative feedback by the target population (a group

of patients with CHD). Later five patients admitted to the hospital (see

Figure 1), fulfilling the study exclusion/inclusion criteria were sought to

provide qualitative feedback regarding the translated scales. This step

was carried out to ensure clarity as well as the use of common language,

and conceptual adequacy and flow of the scales. Furthermore, this group

gave feedback regarding the font size, formatting, line spacing, page

layout, and readability of the items in its final drafted form. All the

patients gave feedback that the questionnaire was easy to comprehend as

it used common everyday language.

Stage 10. Verification and authenticity of the Urdu scale. For

seeking verification and authenticity of the translated instrument, a copy

of the scale in English and Urdu was mailed to the National Language

Authority (NLA), Cabinet Division Islamabad, Pakistan. Minor

grammatical changes were recommended by two Urdu experts of NLA

(see Figure 1) that were incorporated accordingly.

Results

Descriptive and inferential statistical analyses were carried out

using means, paired t-tests, and correlations between English and Urdu

scale scores. In addition, reliability coefficients were calculated for the

study sample.


Figure 2.

Demographic Characteristics of the Study Sample

Table 1.

Demographic Characteristics of the Study Sample

Cases Controls

Men (n = 12)

Women (n = 8)

Men (n = 12)

Women (n = 8)

Demographic

Characteristics

f (%) f (%) f (%) f (%)

12 to 14 years 6(50) 2(25) 5(41.7) 3(37.5)

16 or more years 3(25)

Occupation

Business 2(16.7) Government 4(33.3) 1(12.5) 3(25)

Private 3(25) 5(41.7)

Self-employed 4(33.3) Agriculture

Not working 1(12.5) 1(8.3) 1(12.5)

Retired 1(8.3) 1(8.3)

Housewife 6(75) 7(87.5)

Monthly income

12000 & less 4(33.3) 2(25) 5(41.7) 1(12.5)

6

12

34

2 2

5

2 23

1

5

1 1

Age 35 – 40 41 – 45 46 – 50 51 – 55

Age Categarization

Cases Men (n = 12) Cases Women (n = 8)

Controls Men (n = 12) Controls Women (n = 8)


Cases Controls

Men

(n = 12)

Women

(n = 8)

Men

(n = 12)

Women

(n = 8)

Demographic Characteristics

f (%) f (%) f (%) f (%)

12000 – 20000 3(25) 4(50) 1(8.3) 2(25)

20000 to 35000 3(25) 1(12.5) 3(25) 3(37.5)

35000 & above 2(16.7) 1(12.5) 3(25) 2(25) Mean and Median

monthly income

(26416.66)

(18500.00)

(19625.00)

(15000.00)

(26881.08)

(17,061.50)

(35250.00)

(27500.00)

Marital status

Married 12(100) 8(100) 9(75) 5(62.5)

Not married 2(16.7) 1(12.5) Engaged

Divorced

Widowed 1(8.3) 2(25)

Family system

Nuclear 6(50) 5(62.5) 2(16.7) 2(25)

Joint 6(50) 3(37.5) 10(83.3) 6(75)

Living

Rural 2(16.7) 1(12.5) 2(16.7) Urban 10(83.3) 7(87.5) 10(83.3) 8(100)

Family history of CHD

Present 8(66.7) 4(50) 3(25) 2(25) Absent 4(33.3) 4(50) 9(75) 6(75)

Note. Income is expressed in Pakistani Rupee.


Table 2.

Means, Standard Deviations, t values (paired), Correlation between

English and Urdu Scale Scores and Reliability Coefficients

Variables

M

SD

t

r

α

Perceived

Stress Pre 18.37 7.20 .80

Post 18.15 6.51 0.22 .56*** .79

Depression Pre 11.17 6.38 .88

Post 11.85 7.26 -0.60 .46** .87

Trait anxiety Pre 45.12 11.96 .87

Post 48.07 12.98 -1.37 .41** .85

Trait anger Pre 20.95 6.69 .87

Post 20.52 6.67 0.45 .60*** .88

Hostility Pre 13.40 3.73 .88

Post 12.90 3.61 0.81 .44** .87

Dominance Pre 15.00 3.71 .75

Post 14.27 3.13 1.28 .46** .71

Social

support Pre 58.60 16.78 .85

Post 58.72 17.40 -0.4 .31* .86

Optimism Pre 20.32 6.21 .76

Post 20.37 6.23 -0.09 .86*** .73

Locus of

control Pre 11.43 4.59 .76

Post 11.63 4.46 -.33 .43*** .73

Note. n = 40, df = 39, * p > .05, **p > .01, ***p > .001

There were no significant differences in the mean scores of pre

(English) and post (Urdu) version on any of the scales, suggesting similar

dissemination of the content of the scales in Urdu and English. Pearson

correlation analysis between pre (English) and post-administration (Urdu)

revealed a significant positive correlation demonstrating reasonably high

validity for all the scales. The alpha coefficients revealed moderate to a

high level of internal consistency of all scales for both administrations

respectively. In short, all the Urdu scales indicated high test-retest

reliability.


Discussion

The primary goal of this study was to translate the English

Language instruments to Urdu in order to assess predictors of CHD

another objective and to establish the psychometric properties of these

translated instruments. Overall, the psychometric properties of all these

instruments revealed significant positive inter-scales correlation

demonstrating reasonably high content validity for all the scales. The

alpha coefficients revealed moderate to a high level of internal

consistency of all scales for both administrations respectively. In short,

all the Urdu scales indicated high test-retest reliability. The PSS is a short

and easy to use questionnaire established with acceptable psychometric

properties. The Greek versions of the PSS-14 and PSS-10 exhibited

satisfactory psychometric properties and their use for research and health

care practice is warranted (Andreou et al., 2011). The European Spanish

version PSS demonstrated adequate reliability (internal consistency, α =

.82, test-retest, r = .77), validity (concurrent), and sensitivity (Remor,

2006). The findings confirmed the adequate psychometric properties in

Chinese versions of PSS-10 (Wang, 2011). Internal consistency

reliability coefficients of the CES-D 10 were satisfactory (Cronbach

α = 0.88). The CES-D 10 showed comparable accuracy to the original

CES-D 20 in classifying participants with depressive symptoms. The

sensitivity of CES-D 10 was 91%; specificity was 92%, and the positive

predictive value was 92%. It is a comparable tool to measure depressive

symptoms among HIV-positive research participants (Zhang et al., 2012).

Urdu translation of STAI has demonstrated adequate

psychometric properties with satisfactory test-retest, internal consistency

reliabilities, and convergent validity. The empirical findings show that

the Urdu adaptation of the State-Trait Anxiety Inventory is a reliable and

valid instrument to be used in Pakistan (Butt, 2010).

State-Trait Anger Expression Inventory (STAXI) was adapted

into the Urdu language and used in the present research with overall α .91

(Mushtaq & Najam, 2014). The Portuguese version of STAXI presented

an adequate factorial structure that permits the evaluation of anger

dimensions among clinical patients (Azevedo, Wang, Goulart, Lotufo, &

Benseñor, 2010).


The Greek life orientation test revised appears to be a valid tool in

assessing dispositional optimism in Greek-speaking people and is

expected to facilitate the examination of optimism in Greek-speaking

populations (Lyrakos, Damigos, Mavreas, Georgia, & Dimoliatis, 2010).

LOT-R has good internal consistency (Cronbach's alpha = 0.71 and item-

total correlation coefficients from 0.27 to 0.73, a unitary structure, and

stability over a 3-months period (r = 0.66). Moreover, the Greek version

of the scale exhibited good convergent validity with a single-item

optimism scale (r = 0.73). Principal components analysis revealed a two-

factor structure representing the constructs of optimism and pessimism.

The Greek life orientation test revised appears to be a valid tool in

assessing dispositional optimism in Greek-speaking people and is

expected to facilitate the examination of optimism in Greek-speaking

populations (Lyrakos, Damigos, Mavreas, Georgia, & Dimoliatis, 2010).

The Japanese translation of the revised Life Orientation Test was

completed by 223 Japanese college students. Factor analysis yielded two

factors, namely, Optimism and Pessimism. These factor scales showed

adequate reliability and construct validity (Sumi, 2004).

The research demonstrated that the MSPSS has good internal and

test-retest reliability as well as moderate construct validity. The Urdu

translation of the MSPSS was found to have good construct validity, and

internal consistency (Akhtar et al., 2010). Thai MSPSS is a reliable and

valid instrument to use (Wongpakaran, Wongpakaran, & Ruktrakul,

2011). The simple and short format makes it a useful tool for measuring

perceived social support (Ekbäck, Benzein, Lindberg, & Årestedt, 2013).

Conclusion

In short, it can be safely concluded that evidence regarding

psychosocial risk and protective factors of CHD has mostly been drawn

from Western and European studies, and from studies conducted in South

Asian countries. The evidence regarding psychosocial factors of CHD

was lacking for the Pakistani population.


Limitations and Suggestions

This is acknowledged that there are certain limitations in the

current research; for instance, some dimensional analysis of the

instrument in terms of discriminant and divergent validity could

strengthen its psychometric strength. The study participants were

recruited from one hospital with limited demographic variations, which

may compromise its wider generalization on the national sample as there

are wider population-based specific characteristics across provincial

affiliations of Pakistan. Likewise, this instrument must be put to further

confirmation platforms by collating its data through test-retest reliability

affirmations. Future studies in order to examine the stability of the

instrument are recommended. A major strength of this study is that in the

future well-designed studies can be carried out for endorsement of

psychosocial risk factors for CHD in the Pakistani population. Realizing

a limited number of scales and instruments in Urdu for assessing such

pervasive challenging issues of coronary diseases in the Pakistani

community is one of the most promising elements, yielded by this

research. There have not been indigenous instruments in the domain of

Coronary Heart Disease researches. Thus a comprehensive instrument of

this sort can be used by Pakistani healthcare professionals as a valid and

reliable disease-specific tool to assess the profound dimensions of Urdu-

speaking Pakistani patients with CHD.

Implications

Efficacious utilization of this instrument across different health set-

ups and social stratum is likely to be extremely beneficial for health care

practitioners in the domain of heart disease management. This instrument

is likely to cater simulative line of direction to future researchers and is

likely to support health practitioners in collating data on heart diseases in

Pakistan. In a way, the present study offers ground to carry out research

to infer these factors of CHD prevalent within the Pakistani population.

Upcoming efforts need to be directed at uncovering the risk and

protective factors of CHD in the Pakistani population through the use of

these translated scales in well-designed multi-center prospective cohort

designs.


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Received February 29th, 2016

Revisions Received August 28th, 2020

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